ACCENTURE IS IN NEED OF
Opportunities for US Registered Nurses! (USRN Team Lead)
Responsible to collaborate with healthcare providers and members to promote quality member outcome, to optimize member benefits, and to promote effective use of resources. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care.
Primary duties may include, but are not limited to: Conducts pre-service, concurrent, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Service requests are received from facsimile
Other responsibilities may be review and analysis of post service claims utilizing the member’s benefit contract and health plan guidelines. Completes review of pended claims post service for any of the following: Medical Necessity or Contractual Reviews
Utilizes client specific criteria sets (e.g., Milliman or InterQual), applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to Client’s nursing reviewer and/or Client’s medical staff for review
Responsibilities include conducting any utilization or medical management review activities which require the interpretation of clinical information, but excludes denial determinations.Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract. Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process. Collaborates with providers to assess members, needs for early identification of and proactive planning for discharge planning. Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required
Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards
Requirements:
Minimum 2 years formal clinical experience with 1 year supervisory
Active US State License holder
Willing to work on shifting schedule
Willing to be assigned at either Eastwood or Mandaluyong
Experience in Case Management in the health industry a plus
Send your resume to certifiedpinoyaspirant@yahoo.com
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